Ketamine sedation in mechanically ventilated patients: A systematic review and meta-analysis.

PURPOSE: Ketamine use as a sedative agent in mechanically ventilated patients is increasing. This systematic review and meta-analysis collates existing literature and quantifies the impact of ketamine in mechanically ventilated patients. MATERIALS AND METHODS: EMBASE, MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, conference proceedings, and reference lists were searched. Randomized and nonrandomized studies were included, and two reviewers independently screened abstracts of identified studies for eligibility. RESULTS: Fifteen studies (n = 892 patients) were included. Random effects meta-analytic models revealed that ketamine was associated with a reduction in propofol infusion rate (mean difference in dose, -699 µg/min; 95% CI -1169 to -230, p = .003), but had no impact on fentanyl or midazolam. Ketamine was not associated with mortality, on-target sedation, vasopressor dependence, or hospital length of stay. Cardiovascular complications (e.g. tachycardia and hypertension) were most commonly reported, followed by neurocognitive events, such as agitation and delirium. CONCLUSIONS: The data regarding ketamine use in mechanically ventilated patients is limited in terms of quantity, methodological quality, and demonstrated clinical benefit. Ketamine may play a role as a sedative-sparing agent, but may be associated with harm. High-quality studies are needed before widespread adoption of ketamine earlier in the sedation pathway.

A critical analysis of unplanned ICU transfer within 48 hours from ED admission as a quality measure.

HYPOTHESIS: Unplanned intensive care unit (ICU) transfer (UIT) within 48 hours of emergency department (ED) admission increases morbidity and mortality. We hypothesized that a majority of UITs do not have critical interventions (CrIs) and that CrI is associated with worse outcomes. OBJECTIVE: The objective of the study is to characterize all UITs (including patients who died before ICU transfer), the proportion with CrI, and the effect of having CrI on mortality. DESIGN: This is a single-center, retrospective cohort study of UITs within 48 hours from 2008 to 2013 at an urban academic medical center and included patients 18 years or older without advanced directives (ADs). Critical intervention was defined by modified Delphi process. Data included demographics, comorbidities, reasons for UIT, length of stay, CrIs, and mortality. We calculated descriptive statistics with 95% confidence intervals (CIs). RESULTS: A total of 837 (0.76%) of 108 732 floor admissions from the ED had a UIT within 48 hours; 86 admitted patients died before ICU. We excluded 23 ADs, 117 postoperative transfers, 177 planned ICU transfers, and 4 with missing data. Of the 516 remaining, 65% (95% CI, 61%-69%) received a CrI. Unplanned ICU transfer reasons are as follows: 33 medical errors, 90 disease processes not present on arrival, and 393 clinical deteriorations. Mortality was 10.5% (95% CI, 8%-14%), and mean length of stay was 258 hours (95% CI, 233-283) for those with CrI, whereas the mortality was 2.8% (95% CI, 1%-6%) and mean length of stay was 177 hours (95% CI, 157-197) for those without CrI. CONCLUSIONS: Unplanned ICU transfer is rare, and only 65% had a CrI. Those with CrI had increased morbidity and mortality.

Characteristics of state prescription drug monitoring programs: a state-by-state survey.

OBJECTIVES: Prescription drug monitoring programs (PDMPs) are state-based data collection systems recording controlled substance medications. Currently, 49 states have PDMPs. There are discrepancies in reporting patterns, infrastructure, and oversight between programs. We characterized aspects of each state's PDMP. METHODS: A web search of each state's PDMP was conducted, and a list of all PDMP administrators was obtained. From August 1 to November 31, 2014, a link to a web-based survey was sent to each PDMP administrator. Closed-ended questions included type of access, mandatory-use programs, data sharing, proactive contact with patients or health care providers, details of pharmacy reporting, and protocols for identifying "high-risk" patients. Descriptive statistics were used for analysis. RESULTS: We received a 100% response rate (49/49). Ninety-six percent (47/49) have a physician-accessible PDMP. Most, 68% (32/49), do not have an enrollment mandate for physicians. Prior to prescribing controlled medications, 16% (8/49) require prescribers to access their state's PDMP. More than half of states (53%, 26/49) reported patient prescriptions over the past two or more years. Most, 57% (28/59), reported a lag time of 1 week or longer for patients to appear in a PDMP database after prescription filling. A majority of states (65% 32/49) share data with at least one other state. Protocols exist to identify high-risk patients for prescription drug misuse in 55% (27/49) of states. CONCLUSION: Characteristics of PDMPs are heterogeneous throughout the country. Standardizing data capture, availability, and reporting would improve their usefulness for providers. Copyright © 2016 John Wiley & Sons, Ltd.